Pain & Symptom Management: RQHR Response - Injectable Drug Shortage
|
|
- Blaze Carr
- 5 years ago
- Views:
Transcription
1 Pain & Symptom Management: RQHR Response - Injectable Drug Shortage Carmen L. Johnson, MD CCFP, ABFP, AAHPM, AAPM, ABAM, ABRPM (Pain Medicine) Medical Director Palliative Care Services
2 Disclosures Speakers Bureau, Purdue Pharma Speakers Bureau, Pallium
3 Dedication Dr. Martha Santamaria Dr. Lawrence Librach
4 Learning Objectives Why sudden nationwide shortage of injectable meds? RQHR response to drug shortages Drugs affected, shortage severity Determinants in choosing alternate medications Medications we chose
5 Learning Objectives How did we do? Prescribing changes Any other lessons? Time savings Cost savings Future drug use
6 Headlines February 20, 2012 Sandoz Canada, a leading maker of injectable drugs, announced it has suspended or discontinued production of some drugs, prompting fears of a shortage of critical medications. CBC Online
7 Headlines Caught Health Care Professionals Off Guard Larissa Feldman s Montreal drugstore was among those left in the lurch by the sudden stoppage.... This morning, we ve tried to order some of these products.... [Much] to our surprise, there was none available, Feldman said. CBC Online
8 Headlines February 20, 2012 Significant reduction in output The company [Sandoz] said it was expecting a significant reduction in output and was halting production lines to upgrade operations after quality-control assessments by the [US] Food and Drug Administration warned the factory fell short of FDA standards. CBC News
9 Headlines March 4, 2012 To exacerbate supply concerns, a fire Sunday in the ceiling above the boiler room of Sandoz s Boucherville plant has halted production. CBC Online
10 Headlines March 6, 2012 Health Canada We ve seen an interruption of the supply, and principally of injectable medications for hospitals... Elective surgeries are being cancelled... and there s widespread concern. Dr. Robert Cushman. CBC News
11 Headlines Drugs affected: Painkillers Antibiotics Anaesthetics
12 Headlines March 6, 2012 Health Canada plans to fast-track new sources of certain medications... we do have arrangements with similar organizations like the [Food and Drug Administration] in the U.S. CBC News
13 Headlines Little Did The Canadian Public Know!...
14
15 Headlines Drug Shortage Crisis - United States The U.S. is experiencing a rapidly increasing frequency of drug shortages... Pharmacy and Therapeutics Pub Med Central National Institute of Health, November 2011
16 Headlines USA drug shortages Generic cancer drugs Heart medications Pain medications Morphine Hydromorphone
17 Shortages Reported Intravenous (IV) electrolytes Anaesthetic agents Furosemide Amino acids
18 Headlines March 6, 2012 In Canada, hospitals turn to sharing their supplies Myrella Roy,... Canadian Society of Hospital Pharmacists, says, hospitals typically have a few weeks of inventory on hand... So, when they are notified that a particular drug or number of drugs may be in short supply, they can only fall back on a few weeks worth of inventory. Canadian Press
19 Headlines Week of March 5, 2012 Officials with Alberta Health Services asked doctors to conserve injectable medications. Cancer patients received oral anti-nausea medications instead of injections. CBC News
20 Headlines March 13, 2012 DRUG SHORTAGES COULD MEAN 1890 s STYLE SURGERY! CBC News
21 Headlines Canadians will face medicine from the 1890s or no surgery at all if a shortage of injectable drugs continues, the head of the Canadian Medical Association says. No anaesthesia, no antibiotics. CBC News
22 Headlines March 13, 2012 Canceled or postponed elective surgeries reported in Quebec. CBC News
23
24 Impact on Symptom Management Injectable drugs: Mainly patients end of life difficulty swallowing Hospital Community, hospice, home care program
25 Major Drug Categories Painkillers Anti-nausea Anti-seizure Sedation Secretion control
26
27 RQHR Emergency Meeting February 2012 Pharmacy newsletter weekly or biweekly Drugs shorted and their alternates Newsletters continuing today Categories: grey depleted red less than 2 weeks yellow use judiciously
28 Drugs Affected Pain morphine, hydromorphone Nausea gravol, ondansetron, haloperidol (esp. community) Seizures midazolam, phenobarb, dexamethasone
29 Drugs Affected Sedation midazolam, haloperidol, methotrimeprazine (community) Secretions glycopyrrolate, atropine, hyoscine
30 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Nausea # of Weeks Short dimenhydrinate 56 ondansetron 30 Both on shortage list same week 12 wks
31 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Pain # of Weeks Short fentanyl 34 morphine 17 hydromorphone 15 ketorolac 13 fentanyl & morphine on list same week 1 wk fentanyl & hydromorphone on list same week 1 wk morphine & hydromorphone on list same week 6 wks
32 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Secretion # of Weeks Short atropine 4 glycopyrrolate 18 hyoscine 3 atropine & glycopyrrolate on list same week 1 wk atropine/glycopyrrolate/hyoscine on list same week 0 wks
33 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Sedation # of Weeks Short midazolam 26 propofol 5 ketamine 29 midazolam & propofol on list same week 3 wks
34 Mar. 15/12 Apr. 19/13 (56 wks) Drug - Seizures # of Weeks Short midazolam 26 phenytoin 14 midazolam & phenytoin on list same week 9 wks
35 Mar. 15/12 Apr. 19/13 (56 wks) Drug - # of Weeks Short dexamethasone 1
36 Mar. 15/12 Apr. 19/13 (56 wks) Drug - haloperidol # of Weeks Short community only
37 Determinants Alternative Meds Safety, efficiency Bioavailability (buccal, rectal, transdermal) Onset duration of action
38 Determinants Alternative Meds Duration of effect Dosage frequency Comfort rectal meds gel caps
39 PAIN/DYSPNEA Analgesics MS Contin matrix rectal ok M-Esselon time release beads Hydromorph Contin time release beads Oxyneo - matrix, not for rectal use
40 PAIN/DYSPNEA Rectal Admin MS Contin IR morphine IR hydromorphone IR oxycodone
41 PAIN/DYSPNEA Methadone Suspension/Tabs Very lipophilic Complete absorption 30 min vomiting patients Buccally or rectally
42 PAIN/DYSPNEA Methadone Suspension/Tabs Immediate & long term analgesic effects Immediate 4-6 hr analgesia Repeated dosing longer action analgesic Dose times daily
43 PAIN/DYSPNEA Methadone Suspension/Tabs cont d Long half life Reservoir in fat tissue If buccal volume problematic dose more frequently - smaller amounts increase concentration switch rectal route
44 PAIN/DYSPNEA Methadone Sub-Q Injection Chronic shortage From UK, Health Canada RQHR: pharmacy manpower shortage to mix methadone for sub-q use
45 PAIN/DYSPNEA Fentanyl Transdermal Patches Difficult to titrate Not useful on cachectic patients Several hours therapeutic
46 PAIN Dexamethasone Good pain reliever, esp. bone Neuropathic model of pain Reduces inflammatory markers Modulates ph Reduces noxious pain transmission
47 PAIN Dexamethasone Inflammation/edema brain Reduces seizure risk Anti-emetic, appetite stimulant No info on rectal use
48 PAIN NSAIDs Diclofenac supp mg TID Indomethacin supp mg BID Naproxen supp 500mg BID Ketoprofen supp mg BID No decrease seizure risk brain edema
49 GASTRITIS Omeprazole Can be given PR
50 AGITATION/DELERIUM Antipsychotics 1 st - sub-q important - nursing safety Benzodiazepines 2 nd - can increase agitation
51 AGITATION/DELERIUM Anti-Psychotics Haloperidol sub-q - PCU supply - hospital priority - unavailable community - no info PR Prochlorperazine 10mg supp Chlorpromazine sub-q
52 AGITATION Anti-Psychotics cont d Methotrimeprazine sub-q - not always available Methotrimeprazine 10mg PO unavailable - 25mg available
53 AGITATION Benzodiazepines used rarely Can increase agitation/falls Midazolam sub-q for emergencies Ativan SL or PR or sub-q
54 SECRETIONS Anti-cholinergic Usually atropine, glycopyrrolate Glycopyrrolate shorted - doesn t cross BBB - better for delirium All others can exacerbate delirium Atropine cardiac resuscitation
55 SECRETIONS Anti-cholinergic cont d Amitryptiline PR 25-50mg Q4H PRN Meclizine 25mg PR Q4H PRN compounded Scopolamine patch 1.5mg Q3 days Hyoscine 10mg S/Q Q2H PRN
56 NAUSEA/VOMITING Anti-dopaminergic Prochlorperazine 10 supp Q6H PRN Promethazine mg supp Q8H Haloperidol 0.5 mg 1 mg po q4h prn Could use haloperidol sub-q on PCU
57 NAUSEA/VOMITING Anti-cholinergics nausea with movement Scopolamine patch 1.5mg Q3 days Meclizine compounded
58 NAUSEA/VOMITING 5HT3 antagonists Ondansetron PO EDS frequent dosing - short ½ life Mirtazapine PO wafer Q HS once a day dosing sleep, pain (5HT2) appetite stimulant, mood
59 SEIZURES Barbituates Phenobarbitol sub-q not available community Phenobarbitol sub-q limited hospital
60 SEIZURES Anti-convulsants Carbamazapine 100mg PR Q8H Sodium channel blocker Valproic acid 500mg PR Q8H Gabaergic, sodium, calcium channel blocker Both need frequent dosing
61 SEIZURES Benzodiazapines Midazolam: reserved acute seizure short half life requires frequent dosing $$
62 SEIZURES Benzodiazapines Ativan 2mg sub-q or PR Q6H Ativan SL not effective swallowed Clonazepam 2mg PR Q8H - usually BID - long half life
63
64 HOW DID WE DO? No formal data Perceptions
65 HOW DID WE DO? Pain control adequate Nausea/vomiting - better Secretion adequate
66 HOW DID WE DO? Reduction complaints reduced over sedation Less confusion
67 HOW DID WE DO? Methadone: Very well tolerated Very effective for dyspnea/pain
68
69 Palliative Care Unit Statistics (3A) March 2011 February 2013 Prescribing changes S/Q opioid usage
70 CHANGES IN PRESCRIBING
71 CHANGES IN PRESCRIBING
72 CHANGES IN PRESCRIBING
73 CHANGES IN PRESCRIBING Methadone Changes in Prescribing Orders Methadone Scheduled Methadone prn 7 16
74 CHANGES IN PRESCRIBING Hydromorphone Total Oral Mg Used 80,000 60,000 40,000 20,000 0 HM SR HM IR Total HM ,703 16,086 30, ,656 47,384 70,040
75 CHANGES IN PRESCRIBING Morphine Total Oral Mg Used 15,000 10,000 5,000 0 Morphine SR Morphine IR Total Morphine ,940 4,790 12, ,950 5,730 13,680
76 CHANGES IN PRESCRIBING Oxycodone Total Oral Mg Used 1,500 1, Oxycodone SR Oxycodone IR Total Oxycodone ,055 1,
77 CHANGES IN PRESCRIBING Methadone Total Oral Mg Used 250, , , ,000 50, Methadone 85, ,701
78 CHANGES IN PRESCRIBING Total S/Q Medications Used 100,000 50,000 0 Morphine S/Q Hydromorphone S/Q ,905 76, ,340 72,846
79
80 WHAT OTHER LESSONS? Time savings? Cost savings?
81 NURSING MED ADMIN TIMES Looked at drug admin times Different drugs/routes
82 NURSING MED ADMIN TIMES Analgesics Sub-Q Line Insertion/Priming gather supplies, initiate sub-q line min:sec (most have sub-q line PRN meds) 8:00s hydromorphone sub-q med 3:45s x6 22:30s day buccal methadone 2:15s x3 6:45s day Time saved/pt 15:45s day
83 NURSING MED ADMIN TIMES Analgesics cont d Buccal methadone vs hydromorphone sub-q 5 patients x 15:45s day = 1:18:45s day
84 NURSING MED ADMIN TIMES Analgesics cont d min:sec hydromorphone sub-q med 3:45s x6 22:30s day rectal methadone (ped feed tube) 3:30s rectal methadone TID 3:30s x3 10:30s day Time saved/pt 12:00s day
85 NURSING MED ADMIN TIMES Analgesics cont d min:sec hydromorphone sub-q med 3:45s x6 22:30s day rectal methadone BID 3:30s x2 7:00s day Time saved/pt 15:30s day
86 NURSING MED ADMIN TIMES Analgesics cont d Rectal methadone vs hydromorphone sub-q 5 patients x 12:00s - 15:30s = 1 hour 1:17:30s
87 NURSING MED ADMIN TIMES Anti-emetics ondansetron sub-q 3:45 x3 11:15s sub-q line insertion/priming 8 min Nursing time used: 19 min 15 sec 1st day mirtazapine RD daily 2:15s
88 NURSING MED ADMIN TIMES Anti-Seizure midazolam sub-q Q4H 3 min 18 min/day clonazepam gel tab PR BID 6 min 12 min/day clonazepam long half-life midazolam short half-life, break through seizures
89 COST SAVINGS Analgesics Morphine Injection Hydromorphone Injection Methadone Oral Solution 10mg/ml = 43 cents 2mg/ml = 55 cents 10mg/ml = 37 cents/ml 15mg/ml = 44 cents 10mg/ml = $ mg/ml = $ mg/ml = $6.68
90 COST SAVINGS Analgesics MS Contin Hydromorph Contin Methadone Tablets 15mg = $.104 3mg = $ mg = 17 cents 30mg = $ mg = $ mg = 57 cents 60mg = $.26 6mg = $ mg = 90 cents 100mg = $ mg = $ mg = $ mg = $ mg = $ mg = $3.9355
91 COST SAVINGS Analgesics Fentanyl Patches 12 = $ $ = $ $ = $ $ = $ $ = $ $8.45 (generic vs. brand)
92 COST SAVINGS Analgesics Morphine IR Hydromorph IR Oxycodone IR 5mg = 14 cents 1mg = 15 cents 5mg = 9 cents 10mg = 19 cents 2mg = 22 cents 10mg = 15 cents 20mg = 34 cents 4mg = 22cents 20mg = 15 cents 30mg = 44 cents 8mg = 52 cents
93 COST SAVINGS Benzodiazepines Clonazepam Tablet Midazolam Injection.25mg = 7 cents 1mg/ml x 2ml = $.78 - $1.56.5mg = 7 cents 1mg/ml x 5ml = $ $3.90 2mg = 13 cents 5mg/ml x 1ml = $.41 $1.94 5mg/ml x 2ml = $2.65 Gel caps and lubricants very low - not a factor 5mg/ml x 10ml = $8.82
94 COST SAVINGS Anti-emetics Mirtazapine RD 15mg $ Ondansetron Inj 4mg/2mL $0.68/vial Ondansetron Inj 8mg/4mL $1.25/vial Haloperidol 5mg/ml $1.10ml Methotrimeprazine 25mg/ml $3.25ml
95 COST SAVINGS Secretions Hyoscine butyl bromide 20mg/ml $4.34/ml Scopolamine patch 1.5mg $3.96 Amitryptiline 25mg $0.13 Amitryptiline 50mg $0.25
96 COST SAVINGS Secretions Atropine 0.6mg/ml $0.825/ml Glycopyrrolate 0.2 mg/ml Glycopyrrolate 0.2mg/ml $7.46/2ml $53.80/20ml
97 FUTURE Cost Saving and Time Saving Benefits 1) Methadone as 1st line agent for dyspnea/pain 2) Clonazepam 3) Mirtazapine
98 LEARNING OBJECTIVES Have Learned: Why sudden nationwide shortage of injectable meds RQHR response to drug shortages Drugs affected, shortage severity Determinants in choosing alternate medications Medications we chose
99 LEARNING OBJECTIVES Have Learned: How did we do? Prescribing changes Any other lessons? - time savings, cost savings Future drug use
100
101 THANK YOU TO: Dr. Martha Santamaria Antonio Pedro University Hospital Dr. Lawrence Librach University of Toronto Bev Cross, RN, Nurse Educator, RQHR Dr. Alana Kilmury, Palliative Care Physician RQHR
102 THANK YOU TO: RQHR Pharmacy team Regina Palliative Care Team Members Kathleen Richlen-Tilden, PhD Terrilynn Lowes, Marcia Sehn, Admin Assistants
103 REFERENCES CBC News Online Pub Med Central, US National Library of Medicine, National Institutes of Health, Pharmacy and Therapeutics. Vol. 36(11); Nov 2011; PMC Twycross R, Wilcock A (eds). Palliative Care Formulary, 4 th Ed., Palliativedrugs.com Ltd, United Kingdom, 2012
104 REFERENCES Pereira JL, Associates. The Pallium Palliative Pocketbook: a peer-reviewed, referenced resource. 1 st Ed., The Pallium Project, Edmonton, Canada, 2008 Walsh D, et al. Palliative Medicine, 1 st Ed., Saunders Elsevier, Philadelphia, 2009 Stahl SM, Stahl s Essential Psychopharmacology, 3 rd Ed., Cambridge University Press, New York, 2008
105 REFERENCES Kim S, Shin I, Kim J, Kim Y, Kim K, Kim Ki, Yang S, Yoon J: Effectiveness of mirtazapine for nausea and insomnia in cancer patients with depression. Psychiatry and Clinical Neurosciences 2008; 62: Chang F, Ho S, Sheen M: Efficacy of mirtazapine in preventing intrathecal morphine-induced nausea and vomiting after orthopaedic surgery. Anaesthesia 2010; 65: Teixeira F, Novaretti T, Pilon B, Pereira P, Breda, M: Mirtazapine (Remeron TM ) as treatment for non-mechanical vomiting after gastric bypass. Obesity Surgery 2005; 15:
106
Symptom Management Challenges at End-of-Life
Symptom Management Challenges at End-of-Life Amanda Lovell, PharmD, BCGP Clinical Pharmacist- Inpatient Units Optum Hospice Pharmacy Services February 15, 2018 Hospice Pharmacy Services Objectives Identify
More informationAttach patient label here. Physician Orders ADULT: Palliative Care Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase T;N, Phase: Palliative Care Phase, When to Initiate: Palliative Care Phase Admission/Transfer/Discharge Patient Status Initial
More informationWaterloo Wellington (WW) Symptom Management Guideline for the End of Life (EOL) Medication Order Set for Long Term Care (LTC)
Waterloo Wellington (WW) Symptom Management Guideline for the End of Life (EOL) Medication Order Set for Long Term Care (LTC) May 2018 THE WATERLOO WELLINGTON SYMPTOM MANAGEMENT GUIDELINE FOR THE END OF
More informationUMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards q12h q12h, Temperature Only - Every Shift and PRN Patient Activity Assist as Needed, Bed Position: As Tolerated, elevate to patient
More informationSupportive Care. End of Life Phase
Supportive Care End of Life Phase Guidelines for Health Care Professionals In the care of patients with established renal failure who are in the last days of life References: Chambers E J (2004) End of
More informationApproximate Cost for Patients
Insurance Coverage for Prescriptions Medications that enhance control of pain and symptoms may be costly if patients do not have insurance. In Ontario, the Ontario Drug Benefit (ODB) Program covers prescriptions
More informationUMC Health System Patient Label Here PHYSICIAN ORDERS
Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards q12h q12h, Temperature Only - Every Shift and PRN Patient Activity Assist as Needed, Bed Position: As Tolerated, elevate to patient
More informationMMG035 Symptom Management Guidelines for a Person thought to be in the Last Few Days and Hours of Life
MMG035 Symptom Management Guidelines for a Person thought to be in the Last Few Days and Hours of Life The following pages are guidelines for the management of common symptoms for a person thought to be
More informationCare in the Last Days of Life
Care in the Last Days of Life Introduction This guideline is an aid to clinical decision making and good practice in person-centred care for patients who are deteriorating and at risk of dying. The patient
More informationCLINICAL GUIDELINES FOR END OF LIFE CARE MEDICATIONS IN LONG TERM CARE HOMES
CLINICAL GUIDELINES F END OF LIFE CARE MEDICATIONS IN LONG TERM CARE HOMES OPENING STATEMENT: Insert Facility Name is committed to providing effective end-of-life symptom management to all residents. Symptom
More information9/12/2018. Contents. An Innovative Approach to Symptom Management when the Oral and Sublingual Routes Fail. Symptom Management Challenges at Home
An Innovative Approach to Symptom Management when the Oral and Sublingual Routes Fail Use of a New Rectal Administration Catheter (Macy Catheter, Hospi Corporation) Contents The Challenge of Symptom Management
More informationFor patients and their carers this means smoother symptom control, better support in a crisis, and avoidance of admission if that is their choice.
Bedfordshire Palliative Care Palliative Care Medicines Guidance This folder has been produced to support professionals providing palliative care in any setting. Its aim is to make best practice in palliative
More informationManagement of Delirium in Hospice Patients
Presentation Objectives Management of Delirium in Hospice Patients Lynn Williams, BSPharm Clinical Pharmacist Hospice Pharmacy Solutions Identify the clinical features of delirium Understand the underlying
More informationWhat s New 2003? What new treatments? What have you discontinued? More information please!
What s New 2003? What new treatments? What have you discontinued? More information please! 1 What s New 2003? Submissions = 137 UK = 52 (38%) Doctors = 60% Nurses = 25% Pharmacists = 15% 2 What s New?
More informationOpioid Rotation. Dr Bruno Gagnon, M.D., M.Sc.
Opioid Rotation Dr Bruno Gagnon, M.D., M.Sc. Associate Professor Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval Consultant in Palliative Medicine CHU de Québec-Université
More informationPAIN AND SYMPTOM MANAGEMENT GUIDANCE IN THE LAST DAYS OF LIFE
PAIN AND SYMPTOM MANAGEMENT GUIDANCE IN THE LAST DAYS OF LIFE Reference: DCM029 Version: 1.1 This version issued: 07/06/18 Result of last review: Minor changes Date approved by owner (if applicable): N/A
More informationPalliative Emergencies. Ken Stakiw
Palliative Emergencies Ken Stakiw Disclosure None to disclose for this lecture Have received honoraria from a number of agencies and companies previously Intend to discuss some off label use of medications
More information3/27/2013. Objectives. Psychopharmacology at the End of Life Nicole Thurston, MD
Psychopharmacology at the End of Life Nicole Thurston, MD Psychiatrist Mountain States Tumor Institute Objectives Describe 2 common psychiatric symptoms that can present at or near end of life. Review
More informationLong Term Care Formulary HCD - 08
1 of 5 PREAMBLE Opioids are an important component of the pharmaceutical armamentarium for management of chronic pain. The superiority of analgesic effect of one narcotic over another is not generally
More informationPart 2: Pain and Symptom Management Nausea and Vomiting
Part 2: Pain and Symptom Management Nausea and Vomiting Effective Date: February 22, 2017 Key Recommendations Select anti-nausea medication based on the etiology of the nausea and vomiting. Assessment
More informationPRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT
PRESCRIBING GUIDELINES FOR SYMPTOM MANAGEMENT IN THE DYING PATIENT A collaboration between: St. Rocco s Hospice, Bridgewater Community Healthcare NHS Trust, NHS Warrington Clinical Commissioning Group,
More informationSyringe driver in Palliative Care
Syringe driver in Palliative Care Introduction: Syringe drivers are portable, battery operated devices widely used in palliative care to deliver medication as a continuous subcutaneous infusion over 24
More informationANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL IMPAIRMENT
ANTICIPATORY PRESCRIBING FOR PATIENTS AT END OF LIFE WITH RENAL Doses of opiates must be proptional to current analgesic medication Please refer ALL patients on Methadone Ketamine to SPCT f advice. Patients
More informationPAIN. TREATMENT TABLES Analgesics. NON-OPIOID ANALGESICS Generic Name Trade Names (Examples) Duration Initial Dose
NON-OPIOID SHORT-ACTING LONG-ACTING **** O PAIN TREATMENT TABLES Analgesics NON-OPIOID ANALGESICS Generic Name Trade Names (Examples) Duration Initial Dose Tramadol 50 mg Ultram Every 4 hours 1-2 tabs,
More informationOpioid Pearls and Acute Pain Management
Opioid Pearls and Acute Pain Management Jeanie Youngwerth, MD University of Colorado Denver Assistant Professor of Medicine, Hospitalist Associate Director, Colorado Palliative Medicine Fellowship Program
More informationPalliative Care Impact Survey
September 2018 Contents Introduction...3 Headlines...3 Approach...4 Findings...4 Which guideline are used...4 How and where the guidelines are used...6 Alternative sources of information...7 Use of the
More informationOverview of Essentials of Pain Management. Updated 11/2016
0 Overview of Essentials of Pain Management Updated 11/2016 1 Overview of Essentials of Pain Management 1. Assess pain intensity on a 0 10 scale in which 0 = no pain at all and 10 = the worst pain imaginable.
More informationSYRINGE DRIVER MEDICATIONS
SYRINGE DRIVER MEDICATIONS Christine Hull & Anita Webb Staff Nurses, Hospice in the Home 2015 Analgesics:- Groups of Medication used in Syringe Drivers Morphine sulphate Diamorphine Oxycodone Alfentanil
More informationDoncaster & Bassetlaw Cancer Locality. Palliative Care Core Formulary
Doncaster & Bassetlaw Cancer Locality Palliative Core Formulary Approved by Doncaster & Bassetlaw Hospitals NHS Foundation Trust Drugs and Therapeutics Committee. DJ14/2155 Oct 2014 Review date: Oct 2017
More informationOpioids in the Community: Chronic pain, Palliative Care, and Addiction. Dr Ahmed Jakda September 2017
Opioids in the Community: Chronic pain, Palliative Care, and Addiction Dr Ahmed Jakda September 2017 Outline Context Background Action Delisting Highstrength Long- Acting Opioids Opioid use and prescribing
More informationDelirium. Preconference SHPCA Clinical Day Saskatoon, SK May 13, 2014
Preconference SHPCA Clinical Day 2014 Saskatoon, SK May 13, 2014 Carmen L. Johnson MD, CCFP, ABFP, AAHPM, AAPM, ABAM, ABRPM (Pain Medicine) Medical Director Palliative Care Services, Regina Qu Appelle
More informationOpioid Pain Management. John Manfredonia, DO. Disclosures. Dr. Manfredonia discloses his employment as Regional Medical Director for VistaCare
Opioid Pain Management John Manfredonia, DO Disclosures Dr. Manfredonia discloses his employment as Regional Medical Director for VistaCare VistaCare has provided commercial support for this activity Palliative
More informationE-Learning Module N: Pharmacological Review
E-Learning Module N: Pharmacological Review This Module requires the learner to have read Chapter 13 of the Fundamentals Program Guide and the other required readings associated with the topic. Revised:
More informationHospice High Dollar Medications and Possible Alternatives
Hospice High Dollar Medications and Possible Alternatives Ly M. Dang, PharmD LDang@HospicePharmacySolutions.com Director of Pharmacy Operations Hospice Pharmacy Solutions Topics of Discussion Hospice Coverage
More informationSupporting Last Days of Life Symptom Control Medication Guidance: Algorithm. Agitation & Anxiety
Agitation & Anxiety (Exclude or treat REVERSIBLE causes*) Patient is anxious / frightened, but lucid Patient is confused, agitated and / or hallucinating MIDAZOLAM 2.5-5mg s/c (Max total 24 hour dose of
More informationCare of the Dying Management in Severe Renal Failure
Care of the Dying Management in Severe Renal Failure Clinical Guideline Early recognition of the dying process allows for adequate preparation of the patient, the family and the carers. This clinical guidance
More informationPalliative Care Out-of-hours. A resource pack for West Dorset. Contents:
Palliative Care Out-of-hours. A resource pack for West Dorset Contents: Section 1 Supply of drugs DCH Pharmacy hours and arrangements How to contact a community pharmacist out of hours Palliative care
More informationANSWER # 1 PHARMACOLOGY. Methadone answers Stoltzfus 4/5/2012 METHADONE: WHY GRANDMA S TAKING A DIPHENYLHEPTANE (ANSWERS) JANUARY 26, 2017
METHADONE: WHY GRANDMA S TAKING A DIPHENYLHEPTANE (ANSWERS) JANUARY 26, 2017 Ky Stoltzfus, MD Assistant Professor, Internal Medicine University of Kansas Medical Center ANSWER # 1 Your response might be
More informationSymptom Management. Thomas McKain, MD, ABFM, ABHPM Medical Director
Symptom Management Nausea & Vomiting Thomas McKain, MD, ABFM, ABHPM Medical Director Mr. Jones has nausea and vomiting. May I initiate Compazine from the Comfort Pak? Objectives 1. Delineate the Differential
More informationPRESCRIBING PRACTICE IN DELIRIUM. John Warburton Critical Care Pharmacist
PRESCRIBING PRACTICE IN DELIRIUM John Warburton Critical Care Pharmacist Learning outcomes Modifiable medication risk factors for delirium An appreciation of contributing factors modifiable with medicines
More informationPAIN MANAGEMENT Patient established on oral morphine or opioid naive.
PAIN MANAGEMENT Patient established on oral morphine or opioid naive. Important; It is the responsibility of the prescriber to ensure that guidelines are followed when prescribing opioids. Every member
More informationAnticipatory Medications for End of Life Patients. Doses must be proportional to the current analgesic medication YES NO YES NO
Anticipatory Medications for End of Life Patients oses must be proportional to the current analgesic medication Please refer ALL patients on Methadone or Ketamine to palliative care team for advice. Patients
More informationThe last days of life in hospital and at home
The last days of life in hospital and at home Beaumont Multi-disciplinary Palliative Care Study Day 28/9/2017 Dr Sarah McLean Consultant in Palliative Medicine St Francis Hospice Beaumont Hospital Overview
More informationGuidelines: EOLC Symptom Control for Patients with Normal Renal Function (in Wandsworth)
Guidelines: EOLC Symptom Control for Patients with Normal Renal Function (in Wandsworth) Policy Number : DC020 Issue Date: October 2014 Review date: October 2016 Policy Owner: Head Community Services Monitor:
More informationGG&C Chronic Non Malignant Pain Opioid Prescribing Guideline
GG&C Chronic Non Malignant Pain Opioid Prescribing Guideline Background Persistent pain is common, affecting around five million people in the UK. For many sufferers, pain can be frustrating and disabling,
More informationCare of the Dying. For dosing in severe renal impairment see separate guidance for care of the dying in severe renal failure.
Care of the Dying Early diagnosis of the dying process allows for adequate preparation of the patient, the family and the carers. This clinical guidance covers the prescribing and management of patients
More information1/21/14. Cancer Related Pain: Case-Based Pharmacology. Conflicts of Interest. Learning Objective
Cancer Related Pain: Case-Based Pharmacology Jeannine M. Brant, PhD, APRN, AOCN Oncology Clinical Nurse Specialist Nurse Scientist Billings Clinic Conflicts of Interest Jeannine Brant has served on the
More informationGUIDELINES ON THE MANAGEMENT OF PAIN DUE TO CANCER IN ADULTS
GUIDELINES ON THE MANAGEMENT OF PAIN DUE TO CANCER IN ADULTS Bristol Palliative Care Collaborative Contact Numbers: Hospital Specialist Palliative Care Teams: North Bristol 0117 4146392 UH Bristol 0117
More informationPAIN MANAGEMENT PGY-1. Aaron D. Storms, MD Carin van Zyl, MD Adult and Pediatric Palliative Care, LAC+USC Keck School of Medicine of USC
PAIN MANAGEMENT PGY-1 Aaron D. Storms, MD Carin van Zyl, MD Adult and Pediatric Palliative Care, LAC+USC Keck School of Medicine of USC Perception Matters A builder aged 29 came to the accident and emergency
More informationAnalgesia. This is widely used in palliative care. It has antipyretic and analgesic effects but no anti-
Page 1 of 8 Analgesia The World Health Organisation (WHO, 1990) has devised a model to assist health care professionals in the management of cancer pain. The recommendations include managing pain, by the
More informationMorphine er to oxycontin conversion
Morphine er to oxycontin conversion The Borg System is 100 % Morphine er to oxycontin conversion 17-4-2011 Conversion dose from Oxycontin 40mg 3x a day to morphine sulfate 15 mg?. Oxycontin vs morphine
More informationSYMPTOM MANAGEMENT GUIDANCE FOR PATIENTS RECEIVING PALLIATIVE CARE AT ROYAL DERBY HOSPITAL
SYMPTOM MANAGEMENT GUIDANCE FOR PATIENTS RECEIVING PALLIATIVE CARE AT ROYAL DERBY HOSPITAL If a patient is believed to be approaching the end of their life, medication should be prescribed in anticipation
More information15mg oxycodone is equivalent to how much morphine
15mg oxycodone is equivalent to how much morphine The Borg System is 100 % 15mg oxycodone is equivalent to how much morphine nursing home activity director cover letter 15 mg oxycodone equal to how much
More informationPain management in Paediatric Palliative Care. Dr Jane Nakawesi 14 th August 2017
Pain management in Paediatric Palliative Care Dr Jane Nakawesi 14 th August 2017 Content Management of pain in children Non pharmacological Pharmacological Exit level outcomes The participants will: Know
More informationAnalgesics: Management of Pain In the Elderly Handout Package
Analgesics: Management of Pain In the Elderly Handout Package Analgesics: Management of Pain in the Elderly Each patient or resident and their pain problem is unique. A complete assessment should be performed
More informationSubstitution Therapy for Opioid Use Disorder The Role of Suboxone
Substitution Therapy for Opioid Use Disorder The Role of Suboxone Methadone/Buprenorphine 101 Workshop, December 10, 2016 Leslie Lappalainen, MD, CCFP, dip ABAM Prepared by Mandy Manak, MD, ABAM, CCSAM
More informationNarcotic Equivalence Converter Narcotic Route Dose Duration; Select a drug: mg Convert to: mg Adapted from Tarascon Pocket Pharmacopoeia.
Narcotic Equivalence Converter Narcotic Route Dose Duration; Select a drug: mg Convert to: mg Adapted from Tarascon Pocket Pharmacopoeia. Created: Monday, March 12. Online calculator to convert equianalgesic
More informationPain. Christine Illingworth. Community Nurse St Luke s Hospice 17/5/17
Pain Christine Illingworth Community Nurse St Luke s Hospice 17/5/17 What is pain? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage Pain is whatever
More informationMedications used for symptom control in palliative care
Learning Objectives used for symptom control in palliative care Luis Viana, R. Ph., M.Ed., CGP 1. For common symptoms experienced by the person managed with palliative care: Recognize the symptom to be
More informationBJF Acute Pain Team Formulary Group
Title Analgesia Guidelines for Acute Pain Management (Adults) in BGH Document Type Issue no Clinical guideline Clinical Governance Support Team Use Issue date April 2013 Review date April 2015 Distribution
More informationChoose a category. You will be given the answer. You must give the correct question. Click to begin.
Instructions for using this template. Remember this is Jeopardy, so where I have written Answer this is the prompt the students will see, and where I have Question should be the student s response. To
More informationPrimary Diagnosis YES NO ICD - Code Cancer Cognitive impairment Cardiac Respiratory Neurological Musculoskeletal Respiratory Other
Chart review date: / / Reviewer: Centre Name: Hospital Home RACF DOB: / / AGE: GENDER: Male Female Admission Date: / / Death Date: / / 1. DIAGNOSIS Primary Diagnosis YES NO ICD - Code Cancer Cognitive
More informationRenal Prescribing at End of Life Guidance for Anticipatory prescribing for patients in renal failure (egfr<30) at the end of life
Guidance for Anticipatory prescribing for patients in renal failure (egfr
More informationBACKGROUND Measuring renal function :
A GUIDE TO USE OF COMMON PALLIATIVE CARE DRUGS IN RENAL IMPAIRMENT These guidelines bring together information and recommendations from the Palliative Care formulary (PCF5 ) BACKGROUND Measuring renal
More informationArresting Pain without Getting Arrested
G. Jay Westbrook, M.S., R.N., CHPN - Clinical Director Compassionate Journey: An End-of-Life Clinical & Education Service CompassionateJourney@hotmail.com 818/773-3700 Arresting Pain without Getting Arrested
More information5 MUSCULOSKELETAL SYSTEM
5 MUSCULOSKELETAL SYSTEM 5.01 NON-STEROIDAL ANTIILAMMATORY DRUGS (NSAIDS) *Acetylsalicylic Acid (Aspirin) Tab Soluble 300mg Diclofenac Sodium Tab 25mg, Supp 25mg, 50mg & 100mg (Voltaren) 300-900mg every
More informationOpioid Conversions Mixture of Science and Art
Opioid Conversions Mixture of Science and Art Matthew J. Pingree, MD Assistant Professor Division of Pain Medicine Physical Medicine and Rehabilitation and Anesthesiology Mayo Clinic, Rochester Pingree.Matthew@Mayo.edu
More informationGUIDELINES FOR PRESCRIBING AT THE END OF LIFE FOR PATIENTS WITH RENAL IMPAIRMENT (estimated glomerular filtration rate<30)
GUIDELINES FOR PRESCRIBING AT THE END OF LIFE FOR PATIENTS WITH RENAL IMPAIRMENT These guidelines have been produced in collaboration with Dr Lucy Smyth, Consultant in Renal Medicine, Royal Devon and Exeter
More informationAlgorithms for Symptom Management. In End of Life Care
Algorithms for Symptom Management In End of Life Care The Use of Drugs Beyond Licence (off label) -The Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK regulates the activity of the
More informationEmergency Medical Services Palliative & End of Life Care Assess, Treat and Refer Program
Emergency Medical Services Palliative & End of Life Care Assess, Treat and Refer Program Presenter Terri Woytkiw, RN, MN, CHPCN (c) GNC (c) Manger, Specialty Programs, North Zone, Seniors Health Alberta
More informationPalliative care for heart failure patients. Susan Addie
Palliative care for heart failure patients Susan Addie Treatments The most common limiting and distressing complaint is of fatigue and breathlessness. Optimal treatment strategies relieve symptoms, improves
More informationCare of the Dying Management in Severe Renal Failure
Care of the Dying Management in Severe Renal Failure Clinical Guideline Early diagnosis of the dying process allows for adequate preparation of the patient, the family and the carers. This clinical guidance
More informationOpioid Conversion Guidelines
Opioid Conversion Guidelines March 2015 Gippsland Region Palliative Care Consortium Clinical Practice Group Title Keywords Ratified Opioid, Conversion, Drug, Therapy, Palliative, Guideline, Palliative,
More informationOAT Transitions - focus on microdosing. Mark McLean MD MSc FRCPC CISAM DABAM
OAT Transitions - focus on microdosing Mark McLean MD MSc FRCPC CISAM DABAM Disclosures No pharmaceutical industry or other financial conflicts of interest Study Physician for research funded by Canadian
More informationFighting the Good Fight: How to Convert Opioids Just Right!
Fighting the Good Fight: How to Convert Opioids Just Right! Tanya J. Uritsky, PharmD, BCPS, CPE Clinical Pharmacy Specialist - Pain Medication Stewardship Hospital of the University of Pennsylvania - Philadelphia,
More informationDelirium at End of Life: The Dying Brain
at End of Life: The Dying Brain Carmen L. Johnson MD, CCFP, ABFP, AAHPM, AAPM, ABAM, ABRPM (Pain Medicine) Medical Director Palliative Care Services, Regina Qu Appelle Health Region Altered state of consciousness:
More informationObjectives. What is pain? 9/27/2017. Pain: Does this Hurt? Fall 2017 Dean Fox, MD, FACP
Pain: Does this Hurt? Fall 2017 Dean Fox, MD, FACP Photo credit: http://multiple-sclerosis-research.blogspot.com/2013/10/pain-and-unemployment.html Objectives Consider personal goal of pain management
More informationEquianalgesic Dosing: Making Opioid Interchange Easier. Joseph Bubalo PharmD, BCPS, BCOP Oncology Clinical Pharmacist Assistant Professor Of Medicine
Equianalgesic Dosing: Making Opioid Interchange Easier Joseph Bubalo PharmD, BCPS, BCOP Oncology Clinical Pharmacist Assistant Professor Of Medicine 1 Why Change Opioids? Side Effects Insufficient Pain
More informationRenal Palliative Care Last Days of Life
Renal Palliative Care Last Days of Life Introduction This guideline is an aid to clinical decision-making and good practice for patients with stage 4-5 chronic kidney disease (egfr
More informationOPIOIDS, BENZODIAZEPINES AND THE ELDERLY:
OPIOIDS, BENZODIAZEPINES AND THE ELDERLY: A pocket guide www.nicenet.ca Opioids, benzodiazepines and the elderly: A pocket guide Opioids and Chronic Pain Chronic pain is a major cause of disability in
More informationMedication Management at End of Life
Medication Management at End of Life Molly Curran, PharmD February 9, 2016 PGY2 Critical Care Pharmacy Resident Department of Pharmacy, University Health System, San Antonio, TX Division of Pharmacotherapy,
More informationEnd Stage Liver Disease Regional Audit Casenote Survey
1. This questionnaire is an audit of clinical documentation of patients who have died of end stage liver disease. If you have any questions about how this form should be completed please contact Dr Grace
More informationRestlessness Emotional support Self care
Comfort Airway Restlessness Emotional support Self care MED 12412 9/12 City of Hope Department of Supportive Care Medicine 1500 Duarte Road Duarte, CA 91010 August 2012 The following are recommendations
More informationFrequently Asked Questions
Page 1 Frequently Asked Questions Codeine and all multiple-ingredient products containing codeine are restricted on the AHS Provincial Drug Formulary to patients 18 years of age and older. 1. What does
More informationPo dilaudid versus iv dilaudid
Po dilaudid versus iv dilaudid Search IM/IV/SC 120 mg ratios of morphine to methadone in patients with neuropathic pain versus non-neuropathic an equianalgesic ratio for PO. Dilaudid official prescribing
More informationPAEDIATRIC DOSAGE GUIDELINES For management of post-operative acute pain
Index No: MMG43 PAEDIATRIC DOSAGE GUIDELINES For management of post-operative acute pain Version: 3.1 (Includes anti-emetics and naloxone) Date ratified: July 2013 Ratified by: (Name of Committee) Name
More informationNEUROPATHIC CANCER PAIN STANDARDS AND GUIDELINES
NEUROPATHIC CANCER PAIN STANDARDS AND GUIDELINES GENERAL PRINCIPLES Neuropathic pain may be relieved in the majority of patients by multimodal management A careful history and examination are essential.
More informationDisclosures. Ms. Walsh has nothing to disclose Ms. Broglio is on the speaker s bureau for Genentech and Meda Pharmaceuticals
Anne F. Walsh, MSN, ANP BC, ACHPN, CWOCN Kathleen Broglio, MN, ANP BC, ACHPN, CPE Disclosures Ms. Walsh has nothing to disclose Ms. Broglio is on the speaker s bureau for Genentech and Meda Pharmaceuticals
More informationPalliative Patient in Emergency Department
Palliative Patient in Emergency Department Dr Thiru Thirukkumaran Palliative Care Services NW THO Northwest Regional Hospital, Burnie Northwest Tasmania Outline the Session Introduction What is palliative
More informationGUIDELINES & PROTOCOLS
GUIDELINES & PROTOCOLS ADVISORY COMMITTEE Palliative Care for the Patient with Incurable Cancer or Advanced Disease Part 2: Pain and Symptom Management Dyspnea Effective Date: September 30, 2011 Scope
More informationPalliative Care. Anticipatory Prescribing Guidelines & June Gippsland Region Palliative Care Consortium Clinical Practice Group
Palliative Care Anticipatory Prescribing Guidelines June 2016 Gippsland Region Palliative Care Consortium Clinical Practice Group Policy No. Title Keywords Ratified GRPCC-CPG008_1.1_2016 Anticipatory Prescribing
More informationSCOPING DOCUMENT FOR WHO Treatment Guidelines on pain related to cancer, HIV and other progressive life-threatening illnesses in adults
SCOPING DOCUMENT FOR WHO Treatment Guidelines on pain related to cancer, HIV and other progressive life-threatening illnesses in adults BACKGROUND The justification for developing these guidelines lies
More information(30689) PROT Pain PCA Adult Patient Controlled Analgesia
Diagnosis Allergies Nursing Assess and Document PCA: 1. Assess and document pain rating, sedation level and respiratory rate every 2 hours; assess and document pain rating, sedation level and respiratory
More informationClinical Policy: Nabilone (Cesamet) Reference Number: ERX.NPA.35 Effective Date:
Clinical Policy: (Cesamet) Reference Number: ERX.NPA.35 Effective Date: 09.01.17 Last Review Date: 08.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationWhat Do You Mean The Morphine Isn t Working? Objectives. Opioid Epidemic. Ellen Fulp, PharmD, BCGP Clinical Education Coordinator AvaCare, Inc.
What Do You Mean The Morphine Isn t Working? Ellen Fulp, PharmD, BCGP Clinical Education Coordinator AvaCare, Inc. 42 nd Annual Hospice & Palliative Care Conference September 2018 Charlotte, NC Objectives
More informationPEDIATRIC SPINE SURGERY POST-OP PLAN - Phase: Pediatric Spine Surgery General Orders
- Phase: Pediatric Spine Surgery General Orders PHYSICIAN S Diagnosis Weight Allergies Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert
More informationPalliative Prescribing - Pain
Palliative Prescribing - Pain LAURA BARNFIELD 21/2/17 Aims To understand the classes of painkillers available in palliative care To gain confidence in counselling regarding opiates To gain confidence prescribing
More informationSUBCUTANEOUS AS REQUIRED & SYRINGE PUMP PRESCRIPTION & ADMINISTRATION RECORD (SPAR) Name: Address: Postcode: Date of Birth: NHS Number:
FILE IN PATIENT S COMMUNITY HEALTH RECORD FOLDER : SUBCUTANEOUS AS REQUIRED & SYRINGE PUMP PRERIPTION & ADMINISTRATION RECORD (SPAR) Abbreviations used in this document to be listed here with the full
More informationPAIN MANAGEMENT Person established taking oral morphine or opioid naive.
PAIN MANAGEMENT Person established taking oral morphine or opioid naive. Important; it is the responsibility of the prescriber to ensure that guidelines are followed when prescribing opioids. Every member
More informationEnhanced Community Palliative Support Services. Lynne Ghasemi St Luke s Hospice
Enhanced Community Palliative Support Services Lynne Ghasemi St Luke s Hospice Learning Outcomes Define the different types of pain Describe the process of pain assessment Discuss pharmacological management
More information